Telematic expert system Diabeto. New tool for diet self-monitoring for diabetic patients

OBJECTIVE

To evaluate Diabeto, a computer-assisted diet education system.

RESEARCH DESIGN AND METHODS

One hundred five patients with insulin-dependent diabetes mellitus (IDDM) or non-insulin-dependent diabetes mellitus (NIDDM) were divided into two randomized groups to participate in the evaluation of Diabeto. With free access through Minitel, the French public videotex network, Diabeto helps diabetic patients self-monitor their diets and balance their meals with personalized counseling.

RESULTS

During the first 6-mo study, group A (54 patients) used Diabeto, whereas group B (51 patients) were control subjects. For the second 6-mo study, group B used the system. Evaluation was based on patients' dietetic knowledge, dietary habits, and metabolic balance.

CONCLUSIONS

Diabeto led to a significant improvement of dietetic, knowledge in group A (P less than 0.0005) and also to improved dietary habits; decreased caloric intake in patients initially overeating (P less than 0.05), increase of dietary carbohydrate from 39.7 +/- 0.7 to 42.9 +/- 0.9% in patients with an initial intake less than 45% carbohydrate, and decrease of fat intake from 41.9 +/- 0.9 to 37.4 +/- 1.1% in patients with an initial intake of greater than 35% fat (P less than 0.0005). In the second study, in addition to similar improvements to those observed in the first study, HbA1 decreased from 11.0 +/- 0.4 to 9.9 +/- 0.4% (P less than 0.005) and fructosamine from 5.00 +/- 0.17 to 4.57 +/- 0.17% (P less than 0.001). Diabeto appears to be an effective therapeutic tool in the control of metabolic diseases.

The effect of muesli or cornflakes at breakfast on carbohydrate metabolism in type 2 diabetic patients

Fourteen overweight insulin-treated type 2 diabetic patients ate a breakfast, consisting of either muesli (slow release starch: SRS) or cornflakes (fast release starch: FRS), in either case with milk (46 g carbohydrate), during two consecutive randomized crossover periods of two weeks. The rest of the diet remained unchanged. At the end of each period the patients underwent a glucose tolerance test after an overnight fast without their usual evening insulin injection. Both mean plasma glucose responses curves were identical after the two dietary periods, but plasma insulin was significantly lower at zero (-17%, P less than 0.05) and 2 h (-21%, P less than 0.05) at the end of the muesli (SRS) period as compared to the cornflakes (FRS) period. The mean day-long plasma glucose level (four measurements) at the end of the muesli period was 21% (P = 0.023) lower than after the cornflakes period. These results show that switching, at breakfast only, from standard cereals to slow release starch cereals improves the carbohydrate metabolism of diabetic patients. In addition, the fact that diabetic patients could reduce their insulin requirement (P less than 0.05) with concomitant reduction of their daily blood glucose level implies that sensitivity to insulin was improved by slow release starct foods consumed at breakfast.

Lifetime prevalence of major depression and its effect on treatment outcome in obese type II diabetic patients

OBJECTIVE

To assess the lifetime prevalence of major depression (MD) and its relation to glycemic control among a group of non-insulin-dependent (type II) diabetic subjects seeking obesity treatment and to determine whether a history of MD affected response to treatment.

RESEARCH DESIGN AND METHODS

Sixty-six obese subjects with type II diabetes (22 men, 44 women) completed the Inventory to Diagnose Depression-Lifetime Version before a 52-wk behavioral weight-control program. Weight, glycosylated hemoglobin, fasting blood glucose, and mood were assessed at pre- and posttreatment.

RESULTS

Thirty-two percent of the subjects reported a history of MD. Neither a history of MD nor current depressive symptoms were associated with pretreatment glycemic control. However, a history of MD was related to treatment attrition (52.4 vs. 22.2%, P = 0.03). Subjects with and without a history of MD showed comparable improvements in weight, glycemic control, and mood.

CONCLUSIONS

A history of MD among type II diabetic patients seeking obesity treatment was not related to pretreatment glycemic control but was associated with higher rates of attrition from treatment. Individuals with a history of MD who completed the program did not differ from those with no history of MD in response to treatment.

Behaviour modification in obese subjects with type 2 diabetes mellitus

We have followed prospectively, 46 obese, type 2 diabetic patients for a 55-week period, in order to evaluate the efficiency of an educational programme based on behaviour modification to enhance weight loss and changes of other cardiovascular risk factors. No patient received pharmacological treatment during the study. At the end of the follow-up the patients obtained an average weight loss of 9.250 kg (range: 0.500-17.500 kg); the BMI was reduced from 34.2 +/- 0.8 kg/m2 to 30.6 +/- 1.1 kg/m2 (P less than 0.01); fasting serum glucose descended from 7.9 +/- 0.4 to 6.1 +/- 0.5 mM (P less than 0.05); SBP (systolic blood pressure) decreased from 145.7 +/- 3 to 126.4 +/- 5.1 mmHg (P less than 0.01); DBP (diastolic blood pressure) decreased from 83.5 +/- 2.5 to 65 +/- 2.6 mmHg (P less than 0.01); triglyceride levels were lowered from 164.5 +/- 12 to 109.7 +/- 10 mg/dl (P less than 0.01); HDL-cholesterol levels increased from 1.27 +/- 0.05 to 1.53 +/- 0.12 mM (P less than 0.01). Serum glucose 2 h after a 75 g glucose oral load decreased from 14.9 +/- 0.6 to 12.7 +/- 0.9 mM (P less than 0.05) on week 35 of follow-up. Twelve patients no longer presented a diabetic curve (8 normal oral glucose tolerance test (OGTT) curves, and 4 impaired glucose tolerance (IGT) curves). No significant changes in the parameters studied were obtained in the group of patients on conventional treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

Long-term effects of linoleic-acid-enriched diet on albuminuria and lipid levels in type 1 (insulin-dependent) diabetic patients with elevated urinary albumin excretion

We conducted a 2-year prospective randomised study to investigate the effects of a linoleic-acid-enriched diet on albuminuria and lipid levels in Type 1 (insulin-dependent) diabetic patients with elevated urinary albumin excretion (overnight urinary albumin excretion rate between 10 and 200 micrograms/min). Thirty-eight patients were randomly assigned to increase dietary polyunsaturated:saturated fatty acids ratio to 1.0 by replacement of saturated fat with linoleic-acid-rich products (n = 18, two dropouts, analysis was performed in n = 16) or to continue their usual diet (n = 20). The total fat and protein content of the diet was unaltered. Clinical characteristics, albuminuria, blood pressure, glomerular filtration rate, metabolic control and dietary composition were similar in the two groups at baseline. In the high linoleic acid diet group, linoleic intake rose from 7 +/- 4 to 11 +/- 2 energy % and polyunsaturated:saturated fatty acids ratio rose from 0.60 +/- 0.28 to 0.96 +/- 0.16 (p less than 0.001 compared to usual diet group). The median increase albuminuria was 58% (95% confidence interval, 13 to 109) during the first year (p less than 0.02) and 55% (95% confidence interval, 11 to 127) (p less than 0.01) during the second year. Glomerular filtration rate remained unaltered and filtration fraction tended to rise (p less than 0.05 compared to usual diet group). In the usual diet group, albuminuria did not significantly increased by 16% (95% confidence interval, -17 to 38) and glomerular filtration rate declined during the second year. Blood pressure tended to rise similarly in both groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Diabetes in prison: can good diabetic care be achieved?

OBJECTIVE

To investigate the clinical characteristics and metabolic control of diabetic patients given structured diabetic care in prison.

DESIGN

Survey of diabetic men serving prison sentences during a 22 month period in a large British prison.

SETTING

HM Prison, Walton, Liverpool.

SUBJECTS

42 male diabetic prisoners, of whom 23 had insulin dependent and 19 non-insulin dependent diabetes.

MAIN OUTCOME MEASURES

Episodes of diabetic instability, glycated haemoglobin concentrations, body mass index.

RESULTS

No serious diabetic instability occurred. Between the initial assessment by the visiting consultant diabetologist and a second assessment 10 weeks later glycated haemoglobin concentrations had fallen from 10.8 (SD 2.9)% to 9.8 (2.4)% (p less than 0.05) in prisoners with insulin dependent diabetes and from 8.7 (1.9)% to 7.6 (1.2)% (p less than 0.05) in those with non-insulin dependent diabetes. Good glycaemic control continued, a mean glycated haemoglobin concentration of 7.6 (1.5)% being recorded in seven men remaining in prison for six to 18 months. Mean body mass index (weight (kg)/(height(m))2) did not change during the study (insulin dependent prisoners 23.3 (SD 2.1), non-insulin dependent prisoners 27.9 (3.8)).

CONCLUSIONS

Good diabetic metabolic control is usual in prison, probably due to the rigid dietary regimen, no alcohol, and compliance with treatment. Many younger men had defaulted from their home diabetic clinics, and imprisonment allowed screening for diabetic complications and reassessment of treatment. Structured diabetic care should be offered in all prisons.

[Adaptation reaction to the health resort treatment in patients with diabetes mellitus]

Physical, clinical, biochemical, and functional examinations have been carried out in 70% of patients with diabetes mellitus type 2 treated in health resorts. Patients were treated with diet, drugs, and physiotherapy during a 3-5-week period. It was found, that the whole period of the treatment may be divided into 3 subperiods: period I is characterized by the subjective symptoms produced by the process of adaptation to different environment. This period lasts for 4 days, on average. Periods II and III are characterized by the set of symptoms reflecting a sum of therapeutical physical stimuli. Such symptoms are known in the literature as bath- or spa-reaction. Symptoms of spa-reaction were noted in about 50% of the examined patients. In 21% of them late reaction, i.e. after about 3 weeks, was seen. No worsening of diabetes mellitus was observed during spa-reaction. No correlation between the onset of this reaction and duration of the disease as well as the results of therapy was found. However, spa-reaction was more frequent in the elderly. Period III was followed by the decrease of the symptoms of spa-reaction with marked improvement in glycaemia. Authors' observations lead to some practical conclusions concerning the programs of physiotherapy in dependence on the course of patients' adaptation to the spa. Regulations concerning the routine 24-day treatment period of all patients in health resorts should be revised.

[Why are diabetic patients treated at rheumatological hospitals?]

Retrospective analysis included 316 case histories of diabetic patients treated at the Silesian Rheumatology Hospital in 1987-1988. An analysis included causes of disorders, calcium-phosphorus metabolism disturbances, lipid and purine disorders. Statistical parameters were compared with the type of diabetes mellitus, duration of the disease, sex, age and obesity. There were 10% of inflammatory rheumatic disorders (6.4% rheumatic arthritis, 1.7% of rheumatoid spondylosis and 2% of other disorders) in the analysed case histories, and 32% of degenerative disorders (19% of vertebral column joints and 12.7% of other joints). Degenerative disorders were noted more frequently in patients with diabetes mellitus type 2, treated with insulin, while spondylopathies were particularly frequent in female patients of this group. Biochemical disorders in the form of hypocalcemia and hypophosphatemia, hypertriglyceridemia, hyperuricemia, signs of lesions to the liver and kidneys were more increasing with the duration of the disease and the degree of insulin-dependence. Locomotive system disorders are not related only to primary articular lesions. They depend also on diabetic neuro-vascular complications and osteopenia.

A simple clinical approach to discriminate between "true" and "pseudo" secondary failure to oral hypoglycaemic agents

To discriminate between true secondary failure (TF) and pseudo-secondary failure (PF) to oral hypoglycaemic agents, we studied 34 non-obese non-insulin-dependent diabetic patients who were being treated with these drugs. Nine were in good control (GC) with oral treatment, while 25 showed apparent SF. During a controlled hospital diet, fasting blood glucose remained persistently high in 15 of these patients (TF), while in the other 10 patients it clearly improved (PF). Fasting plasma glucose (FPG) and HbA1c were higher and body mass index (BMI) was lower in TF patients than in PF patients (P less than 0.01). C-peptide concentrations differed significantly among the three groups both in the fasting state (TF 0.25 +/- 0.02 nmol/l, PF 0.70 +/- 0.03 nmol/l, GC 0.74 +/- 0.03 nmol/l; P less than 0.0001) and 6 min after glucagon injection (TF 0.50 +/- 0.04 nmol/l, PF 1.02 +/- 0.06 nmol/l, GC 1.14 +/- 0.07 nmol/l; P less than 0.0001). C-peptide and plasma insulin curves obtained after a standard mixed meal also showed significant differences (P less than 0.001). In particular, there was a statistically significant difference between GC and PF versus TF (P less than 0.05), while there was no statistical difference between PF and GC. We conclude that some patients with apparent SF can improve their metabolic control if they strictly adhere to a correct diet (PF); a single measurement of basal C-peptide concentration or examination of the C-peptide and insulin responses to a meal are useful indicators for distinguishing patients with PF from those with TF to oral hypoglycaemic agents.(ABSTRACT TRUNCATED AT 250 WORDS)

Management of insulin-dependent diabetes mellitus

Insulin therapy has been lifesaving for patients with insulin-dependent diabetes mellitus. Unfortunately, longer lifespan has unmasked microvascular, neurological and macrovascular complications that result in profound morbidity and increased mortality. Driven by the conviction that better physiological control of glycaemic levels will prevent and/or ameliorate long term complications, and by the desire to make diabetes care as user-friendly as possible, clinical research efforts have led to the development of new treatment methods with the aim of achieving near normal metabolic control. Such methods include the use of self monitoring, multiple daily insulin injection regimens, external and implantable insulin pumps, and whole organ pancreas and isolated islet cell transplantation. In addition, dietary manipulation, including the use of alpha-glucosidase inhibitors, has played a role in controlling glycaemia.

Glycemic and insulinemic responses after ingestion of ethnic foods by NIDDM and healthy subjects

In an attempt to apply the concept of glycemic index (GI) and insulinemic index (II) to local eating habits, we examined the plasma glucose and insulin responses in subjects with non-insulin-dependent diabetes mellitus (NIDDM) and healthy subjects to five mixed meals of different ethnic origins. All meals contained 50 g carbohydrate and were compared with a 50-g glucose load. The GI was highest for the Polish dish and lowest for the Syrian dish (66 +/- 5.5 vs 24 +/- 5.1). However, the II was the highest for the standard meal and lowest again for the Syrian dish (174 +/- 27 vs 66 +/- 25). A high correlation was found between the area under the glucose curve and the predicted GI in both NIDDM and healthy subjects. The GI concept is valid and potentially useful in diet planning and legume foods should be incorporated as a carbohydrate source when diets are being planned for NIDDM subjects or individuals with impaired glucose tolerance.

Relationship of self-efficacy and binging to adherence to diabetes regimen among adolescents

OBJECTIVE

To test the hypothesis that poorer adherence to diabetes care is related to four variables associated with self-concept in adolescents with diabetes: self-esteem, self-efficacy, depression, and binging behavior. In addition, we expected adolescent females to be less adherent to diabetes care.

RESEARCH DESIGN AND METHODS

We recruited 193 consecutive patients (aged 13-18 yr) with insulin-dependent diabetes mellitus during their regular quarterly visit to a diabetes clinic in a large urban hospital. Participants completed the Rosenberg Self-Esteem Scale, the Children's Depression Inventory, an assessment of the frequency of binging in the past 3 mo, and parallel forms of an adherence scale and a self-efficacy scale that were developed for use in this study.

RESULTS

Adolescents who reported lower adherence tended to report lower self-esteem (r = 0.45, P less than 0.001) and self-efficacy (r = 0.57, P less than 0.001), more depressive symptoms (r = -0.50, P less than 0.001), more binging (r = -0.36, P less than 0.001), and had higher HbA1c (r = -0.24, P less than 0.001) than those with higher adherence scores. Together, the psychological variables accounted for 50% of the variance in adherence. There was no sex difference in reported binging, but, as expected, adolescent females reported less adherence overall (F[7,184] = 2.5, P = 0.018).

CONCLUSIONS

Treatment adherence in adolescents with insulin-dependent diabetes mellitus is associated with behavioral and psychological variables. These findings suggest that specific behavioral and cognitive interventions could be used to improve adherence in those individuals who lack confidence in their ability to perform diabetes-related tasks.

Nutritional recommendations for diabetic patients and treatment with alpha-glucosidase inhibitors

Adjunctive treatment with acarbose (possibLy together with sulphonylurea or insulin treatment) can be effectively utilised to achieve blood glucose control if postprandial hyperglycaemia is a problem and cannot be sufficiently controlled by dietary modifications. The alpha-glucosidase inhibitor, acarbose, should be taken with meals that are rich in complex carbohydrates and low in simple sugars, as recommended by diabetes associations, to achieve the greatest possible benefit from treatment.

Insulin binding to trophoblast plasma membranes and placental glycogen content in well-controlled gestational diabetic women treated with diet or insulin, in well-controlled overt diabetic patients and in healthy control subjects

Insulin binding to trophoblast plasma membranes and the placental glycogen content were measured in twelve healthy women, in eleven well-controlled gestational diabetic women who were treated either with diet alone (n = 4) or with insulin (n = 7) and in 18 women with well-controlled overt diabetes mellitus (six White B; four White C; eight White D). The competitive binding assay was carried out with 22 concentrations of unlabelled insulin. Binding data were analysed by a non-linear direct model fitting procedure assuming one non-cooperative binding site. Maximum specific binding was unchanged in the total collective of gestational diabetic women, but was decreased by 30% in those treated with diet (6.2 +/- 2.2%) and increased by 90% in insulin-treated women (16.4 +/- 10.2%) as compared to the control subjects (8.7 +/- 2.5%). The diet-treated women had only 40% as many and those treated with insulin had more than twice as many receptors compared to control subjects on a per mg protein basis and if expressed per total placenta. In patients with overt diabetes mellitus maximum specific binding (18.5 +/- 10.6%) was higher (p less than 0.05) due to more receptors compared to control subjects but was similar to the insulin-treated gestational diabetic patients. Maximum specific binding and receptor concentrations did not correlate linearly with maternal plasma insulin levels. Receptor affinities were virtually similar in all groups (1.8 x 10(9) l/mol). The placental glycogen content was reduced (p less than 0.05) to about 80% of that of control subjects in the diet-treated collective, whereas it was unchanged compared to control subjects in the insulin-treated gestational diabetic women despite a 40% increase (p less than 0.001) of the maternal-to-cord serum glucose ratio. In overt diabetic patients the maternal-to-cord serum glucose ratio and the placental glycogen content were higher (p less than 0.05) than in the control subjects. We conclude that trophoblast plasma membranes from gestational diabetic women treated with diet alone express less and those from women treated with insulin express more insulin receptors than those from a healthy control group in vitro. These differences could not have been disclosed without consideration of the mode of treatment. Trophoblast plasma membranes from overt diabetic women have more insulin receptors than those from healthy control subjects.

Management of non-insulin-dependent diabetes mellitus

The initial management of non-insulin-dependent diabetes mellitus (NIDDM) should include patient education, dietary counselling and, when feasible, individualised physical activity. It is only when such measures fail that drug therapy should be considered. Dietary management of NIDDM includes a restriction in calories, and these should be appropriately distributed as carbohydrates, lipids and proteins. Supplementation of the diet with soluble fibre and supplementation with magnesium salts if hypomagnesaemia is demonstrated, is recommended. However, supplementation with fish oils or with fish oil-derived omega-3 fatty acids is not currently recommended. Oral drug therapies used in NIDDM include sulphonylurea derivatives, which are a first-line treatment in patients who are not grossly obese, metformin, which is the treatment of choice for obese patients, and alpha-glucosidase inhibitors such as acarbose, which are used mainly to reduce postprandial blood glucose peaks. These types of drugs can be used alone or in combination. Insulin therapy may be required to achieve adequate control of blood glucose levels in some patients. In several instances, it is suggested that insulin therapy be combined with sulphonylureas (essentially when residual insulin secretion is present), with metformin, or with alpha-glucosidase inhibitors. The treatment of disorders associated with NIDDM, such as obesity, hypertension or hyperlipidaemia, requires particular attention in diabetic patients, since some drugs can adversely affect glycaemic control. Oral drugs for the treatment of NIDDM include sulphonylurea derivatives used in first-line treatment in patients who are not grossly obese, metformin, which is often the treatment of choice for obese patients and, more recently, the alpha-glucosidase inhibitors, such as acarbose, which are effective in reducing the postprandial rise in blood glucose.

Alternatives to the exchange system for teaching meal planning to persons with diabetes

Although the most well known, exchange lists are not the only meal-planning approach for persons with diabetes. This paper outlines the steps in the nutrition education process, including initial and continued education stages, and presents six alternative approaches for individualizing meal planning. These include the High Carbohydrate-High Fiber Exchange System, Calorie/Fat Counting, Total Available Glucose, the Point System, Month of Meals, and Individualized Sample Menus. The approaches are rated according to emphasis on weight loss, glucose control, and ease of learning and according to type of diabetes. A complete resource guide is provided.

Non-insulin-dependent (type II) diabetes mellitus

Non-insulin-dependent (type II) diabetes mellitus is an inherited metabolic disorder characterized by hyperglycemia with resistance to ketosis. The onset is usually after age 40 years. Patients are variably symptomatic and frequently obese, hyperlipidemic and hypertensive. Clinical, pathological and biochemical evidence suggests that the disease is caused by a combined defect of insulin secretion and insulin resistance. Goals in the treatment of hyperglycemia, dyslipidemia and hypertension should be appropriate to the patient's age, the status of diabetic complications and the safety of the regimen. Nonpharmacologic management includes meal planning to achieve a suitable weight, such that carbohydrates supply 50% to 60% of the daily energy intake, with limitation of saturated fats, cholesterol and salt when indicated, and physical activity appropriate to the patient's age and cardiovascular status. Follow-up should include regular visits with the physician, access to diabetes education, self-monitoring of the blood or urine glucose level and laboratory-based measurement of the plasma levels of glucose and glycated hemoglobin. If unacceptably high plasma glucose levels (e.g., 8 mmol/L or more before meals) persist the use of orally given hypoglycemic agents (a sulfonylurea agent or metformin or both) is indicated. Temporary insulin therapy may be needed during intercurrent illness, surgery or pregnancy. Long-term insulin therapy is recommended in patients with continuing symptoms or hyperglycemia despite treatment with diet modification and orally given hypoglycemic agents. The risk of pancreatitis may be reduced by treating severe hypertriglyceridemia (fasting serum level greater than 10 mmol/L) and atherosclerotic disease through dietary and, if necessary, pharmacologic management of dyslipidemia. Antihypertensive agents are available that have fewer adverse metabolic effects than thiazides and beta-adrenergic receptor blockers. New drugs are being developed that will enhance effective insulin secretion and action and inhibit the progress of complications.

Is exercise safe or useful for gestational diabetic women?

The mainstay of management of the gestational diabetic woman is dietary manipulation to achieve and maintain normoglycemia. If normoglycemia cannot be sustained by diet alone, then insulin therapy is initiated. We instituted a series of studies to observe the value and safety of a cardiovascular fitness program to improve glucose tolerance in gestational diabetic women. We first evaluated the safety for pregnant women of five aerobic exercise machines by observing the effect of these different forms of exercise on uterine activity during the third trimester. We found that upper-extremity exercise produced no uterine contractions, but lower-extremity exercise tended to produce contractions. Upper-extremity exercise, in addition to dietary therapy, was then assigned to 10 gestational diabetic women who were matched for amount of glucose intolerance to 10 gestational diabetic women managed by diet alone. The mean fasting plasma glucose +/- SD after 6 wk was 4.87 +/- 0.34 mM in the diet group versus 3.89 +/- 0.37 mM in the diet-plus-exercise group. The mean postglucose challenge in the diet group was 10.40 +/- 0.16 mM versus 5.9 +/- 1.1 mM in the diet-plus-exercise group. Thus, upper-arm exercise may provide a useful treatment option for gestational diabetes and may obviate the need for insulin.

Rationale for insulin management in gestational diabetes mellitus

A prospective study was undertaken to test the hypothesis that insulin treatment in patients with gestational diabetes mellitus (GDM) with fasting plasma glucose (FPG) greater than 5.3 mM significantly reduces adverse perinatal outcome. Assigned to insulin or diet treatment based on FPG were 471 GDM women. Four factors believed to be associated with infants large for gestational age (LGA) were evaluated: FPG, overall glycemic control, maternal weight, and treatment regimen. We found that when glycemic control was optimized, the key factors related to large infants were FPG and treatment modality. In the low-FPG group (less than 5.3 mM), diet therapy achieved an incidence of 5.3% LGA. When insulin therapy was used to optimize control, an incidence of 3.5% LGA was found. Patients in the mid-FPG group (5.3-5.8 mM) had a higher increased rate of LGA (28.6%) for diet-treated versus insulin-treated women (10.3%). In addition, a fourfold increased risk for LGA was found in the diet-treated obese subjects in the mid-FPG group compared with insulin-treated obese women. Finally, treatment with insulin resulted in similar incidence of LGA within all FPG groups. We concluded that FPG greater than 5.3 mM can be the basis for initiation of insulin treatment in GDM subjects with optimization of glycemic control as the goal. This approach may contribute significantly to reduced neonatal risk and may foster a standardized method for rapid and effective assignment to treatment.

A comparison of the clinical features and vascular complications of diabetes between migrant Asians and Caucasians in Leicester, U.K

907 consecutive patients, (456 Asian and 451 Caucasian) were assessed, employing a similar methodology to the multi-centre WHO study. The Asians were older at diagnosis (46.5 years compared with 40.6 years, P less than 0.01); they had a shorter duration of diabetes (6.3 years versus 11.4 years, P less than 0.1), a higher rate of diabetes in the first degree relatives (29.5% compared with 16%, P less than 0.1), less ketonuria at presentation (85.3% compared with 47.8%, P less than 0.1), and fewer were treated with insulin (31.4% compared with 68.7%). Comparing the prevalence of complications between Asians and Caucasians, the ischaemic heart disease rate was similar; peripheral vascular disease was less (3.7% Asian, 9.3% Caucasian, P less than 0.05); retinopathy was less (11.6% Asian, 32.3% Caucasian, P less than 0.01) but renal disease was more (22.3% Asian, 12.6% Caucasian, P less than 0.01). After adjusting for age, sex, duration of diabetes, age at diagnosis, hypertension, smoking and treatment with or without insulin, these differences remained significant. Multivariate logistic regression failed to reveal a significant contribution due to any of the above variables, or due to body mass index (BMI), haemoglobin A (HbA1), or physical activity in the prevalence of complications in Asians compared with Caucasians. Marked heterogeneity in the complications of diabetes in the two ethnic groups studied was found, but must be confirmed from population-based studies.

Metabolic effects of hypocaloric diets in management of gestational diabetes

Although hypocaloric diets have been advocated for the management of the obese gravida and the obese mother with gestational diabetes, there is no general agreement on how severely calories should be restricted or on how this therapeutic approach compares with insulin therapy. The lack of consensus is in part because of the lack of studies comparing insulin management with the effects of different degrees of hypocaloric feeding and its effects on metabolism and glycemic status. We review the effects of 50 and 33% calorie restriction on glycemic status and intermediary fuel status in obese gestational diabetic subjects and compare the results with the administration of 20 U NPH and 10 U regular insulin every morning, a therapy of proven value in reducing macrosomia in gestational diabetes. When the two calorie-restriction regimens were compared after a 9-h overnight fast, glycemic status improved 10-20% on both. Ketonuria increased about twofold with 50% calorie restriction, but on average no increase in ketonuria was seen on the 33% calorie-restriction regimen. Both calorie-restriction programs led to a reduction in levels of plasma triglyceride, a correlate of infant birth weight. In contrast, the insulin regimen diminished ketonuria, but glycemic status improved little, and plasma triglyceride concentrations did not decline. Although more studies are needed to confirm these trends, the beneficial effect of 33% calorie restriction, which occurred without marked ketonuria, is consistent with previous studies in gestational diabetes. In addition, the simultaneous improvements observed in plasma glucose and triglyceride concentrations suggest that moderate calorie restriction may be valuable in preventing macrosomia in the offspring of the obese subject with gestational diabetes.(ABSTRACT TRUNCATED AT 250 WORDS)

Variation of endogenous insulin secretion in association with treatment status: assessment by serum C-peptide and modified urinary C-peptide

The variation of endogenous insulin secretion in association with fasting plasma glucose (FPG) level and the modality of treatment was assessed using serum C-peptide levels before and after breakfast and the corrected value of 24-h urinary C-peptide (24 h-UCP) in inpatients with non-insulin-dependent diabetes mellitus. The corrected value calculated as 24 h-UCP/(urinary C-peptide to creatinine clearance (CCP/CCR) ratio in the fasting state x 10) was correlated with the sum of day-long serum C-peptide levels (r = 0.93) more closely than the measured value of 24 h-UCP (r = 0.79) in 9 patients. In 52 patients treated with diet alone, 38 with sulfonylurea and 28 with insulin, fasting serum C-peptide level did not vary with FPG level, and the increment of serum C-peptide level after breakfast and the corrected value of 24 h-UCP decreased with the rise in FPG level in each treatment. These indexes were the lowest in insulin treatment among the patients with similar FPG levels. In conclusion, 24 h-UCP was demonstrated to be able to reflect day-long endogenous insulin secretion more faithfully after the correction with the CCP/CCR ratio. It was estimated that the insulin response to breakfast and day-long insulin secretion decreased with the rise in FPG level, but basal insulin secretion was maintained over a wide range of FPG levels in each treatment. Endogenous insulin secretion seemed to be somewhat suppressed or rested by exogenous insulin in insulin-treated patients.

[Current aspects of diagnosis and therapy of diabetes mellitus]

Additions to the categorisation of the forms of diabetes, new knowledge about genetic facts and facts of immunology concerning heredity, etiology and pathogeny of the diabetes are very important for the innovations as well as the utilization of screenings for type I an type II diabetes. As for the laboratory examinations, the proof of the glucose fixed to the hemoglobin or to the albumin of the plasma has become important. The importance of the intensified insulin therapy with the technical support of pumps or injection facilities is emphasized with reference to the hyperinsulinism as one risk. The therapies with immune suppressive, with inhibitors of glucosidase and aldose-reductase and with the transplantation of pancreas or Langerhans' cells promise enormous improvements in the course of diabetes.